HomeMy WebLinkAboutG-11-867 •
M • MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
mi�t=fPO nia(//b) ,Mass. Datv-/77 20# Permit NV I '16
71
C I` gy Building Location A�h ///� /�/l(()/ gip( y
°� Owner's Name `moi
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• Owner Teti/41/n � Type of Occupancy as
New ❑ Renovation 0/ Re / .-placement �C Plan Submitted: Yes ❑ No p3
FIXTURES ( /
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SUB-BSMT
BASEMENT
1°T FLOOR
2ND FLOOR
3RD FLOOR
4"FLOOR
5"FLOOR
6"FLOOR
7T"FLOOR
8T"FLOOR i / /�
(2 Installing Company Name E9(('i'flSk)/t) P-/7 Check one: Certificate
Address 0 77E &e 9 /to Me-. / / Eorporation sJS1
5; Yearn�J��IA% 'Mg o2t66/ 0 Partnership
Business Telephone# -�LJt/ -.3 9' "?7 7 7Le �7 0 Firm/Co. )
Name of Licensed Plumber or Gas Fitter v r//-CJ/) g /i(J/.12.4
INSURANCE CO RAGE:
I have a curre lability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142.
Yes No ❑ •
If you have checked des,please fcate the type coverage by checking the appropriate box.
A liability insurance policy Other type of Indemnity 0 Bond 0
OWNERS INSURANCE WAIVER:I em aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass.General Laws,and that my signature on this permit application waives this requirement.
Check o,.:
• - - Agent ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered)In ,•ova applicat v are a • urate : best of my
•
knowledge and that all plumbing work and Installations performed under the permit issu•• • thi- •Iicatio I •.-in comp ith all
ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General La •-
By
Title
Type of License: -
••Plumber
•Gas fitter
Ait
ignature o Licensed Plumber or Gas Fitter
j,q
✓-Jourter License Number /?4
City/Town •Journeyman
APPROVED(OFFICE USE ONLY)